Abstract

Body packers are smugglers who swallow packets of illicit drugs as a trick of transporting illegal drugs. The main medical hazards for a body packer are the potential possibility of acute drug poisoning due to torn packets, gastrointestinal tract obstruction, and perforation. Here, we report a 36-year-old male who presented to the Emergency Department (ED) with abdominal pain, nausea, and vomiting form 3 days ago, confessing that had vomited 3-packets containing opium and defecated 3 packs following the in-home Polyethylene Glycol (PEG) prescription by his care partner. At the admission, the patient had mild abdominal pain in the epigastric area with no tenderness. The requested abdominal X-ray revealed multiple oval shape foreign bodies in the gastrointestinal tract. An hour after conservative treatment with oral laxatives, the patient’s abdominal pain got worsens and physical examination indicating the possibility of peritonitis. Following the surgery, a total of 84 packets were removed; while the duodenum and whole bowel were not containing any packets. To our knowledge, this case is one of the heaviest body packets reported in the literature. In addition, all packets retention in the stomach is rarely been reported. This case should be taken into account for the training of anti-drug police forces.

Keywords: body packer; smuggle; opium; drug traffickers; drugs.

Citation: Kamaloddini MH, Foroughian M, Kalani N, Hatami N, Vafadar Moradi E, et al. Numerous opium packets retention in the stomach. J Clin Images Med Case Rep. 2022; 3(3): 1758.

Introduction

Traffickers use a variety of methods to smuggle drugs. Embedding drugs in various items such as clothing, foods, baby accessories, cosmetics, etc. has been one of their tricks in recent years [1]. However, Smugglers are still trying to move these drugs by very unconventional methods. One of the most inhumane ways is body packing. Swallowing is one of the best ways to get drugs into prison [2]. Prisoners who go on leave return to prison by storing drugs in their stomachs and selling those drugs at the prison [3]. Those who voluntarily or forcibly swallow drugs in pre-made nylon packages for smuggling are called body packers [4]. While there are some cases of pushing drug packets in the rectum or vagina, called body pushing [5]. In the swallowing method, criminals prepare plastic covers that are of the right material and are resistant to stomach enzymes. So that it does not tear in the stomach and intestines [6]; while in some cases, torn packets of swallowed drugs lead to severe intoxication, and in some cases [7,8], bowel obstruction, ileusand perforation might happen [9]. On average, anyone who volunteers to transport drugs swallows between 40 and 50 packets and discards them a few hours later [10]. Due to the urgent need for control of drug transporters and smugglers, studying clinical aspects of body packing phenomenon, as well as manifestations, physical examination, and treatment is necessary. In this paper, we report a 36-year-old body packer of 90 opium bags being stuck in the stomach.

Case presentation

A 36-year-old male was referred to the ED of Imam Reza hospital of Mashhad city, complaining of abdominal pain, nausea, and vomiting from 3 days ago. A care partner who was a nurse was accompanying him. The care partner confessed swallowing multiple unknown packets by his patient and that the patient had received Polyethylene Glycol (PEG) doses at home and had vomited 3 of the packets and defecated 3 pack. At the admission, the patient had mild abdominal pain in the epigastric area with no tenderness in the abdomen; while a stiffness being palpated in the epigastric area with a rigidity being sensed in a low depth of palpation in the epigastric area. The patient was not febrile and his blood pressure was 115/80 mmHg. As there was not any evidence of opium poisoning (no altered level of conscious, no myosis, and normal breathing counts of 14 per minute), abdominal X-ray showed multiple opacities in the abdomen in favor of foreign bodies (Figure 1). The patient confessed to swallowing opium packets 4 days ago, not mentioning the count. After 3-hour of oral laxative therapy, abdominal pain increased and the patient got severe diffuse abdominal tenderness. A venous blood gas report showed alkalosis with PH: 7.519, PO2: 65.2, PCO2: 35.3, HCO3: 28.8. CBC showed WBC: 20.0, Hb: 15.6, Platelet: 230, Neut: 83.0, Lymph: 10.3. So patient was scheduled for gastrotomy surgery.

Following the surgery, the abdomen was clean and had no fluid or digestive secretions. The stomach was completely dilated and some of the drug packets could be palpated from the stomach. A total of 84 packets were removed from the body, weighting 20 grams (Figure 2). The patient was discharged 4 days later with a good health condition.

Discussion

In this study, we presented a young male body packer of 90 opium packets, that all packets were stuck in the stomach. While our patient was treated with surgical intervention, a small number of these body packers may seek medical attention for obstruction, gastrointestinal bleeding, or symptoms of poisoning. As well as our case, these people or their companions, are afraid of further legal problems, refuse to give an accurate history. It is very difficult to diagnose these patients as well as the contents of the packages, and they practically do not visit until they show signs of intoxication, obstruction, or gastrointestinal bleeding due to the pressure of the package. In our case, there were no symptoms of intoxication; while obstruction and perforation were more potential causes of symptoms. Obstruction is less reported in the literature; Hantson et al. reported a case of gastric obstruction in a man who had swallowed 92 cocaine-containing packages which were treated by the primary four days laxative therapy and gastrotomy due to gastric distension as well as our case [9]; while our case just tolerated 3 hours of laxative therapy without defecating any packets. We used a simple X-ray to diagnose the patient but other studies have also used CT-scan images. Due to the density of the packages, it may not be necessary to use a contrast agent [11,12]. Packets on plain abdominal imaging may be dense, and their most important differential diagnosis is fecal impaction. The sign of a pair of condoms, which is actually caused by air being trapped between the contents of the package and its walls, as well as the location of some packages, can help with the diagnosis [13].

If the patient carries a dangerous substance such as cocaine because there is no antidote for it, the treatment will be surgical, and if carrying a substance such as heroin, which has low absorption and naloxone can be used as an antidote, treatment could be purely medical [14]. While surgery is recommended in perforated packets; in Vahabzadeh study, several apnea events and treatment by naloxone concerned physicians to a source of the huge amount of heroin in the body in form of body packing that was confirmed by plain X-ray and CT- scan [15].

Here, we reported a 36-year-old body packer of 90 opium bags being stuck in the stomach that was treated by gastronomy surgery. In our insight, this case is one of the heaviest body packersin literatures. Also, 84-packets retention in the stomach is seldom been accounted for. This case ought to be considered for preparing police forces.

Declarations

Acknowledgement: This research was supported by a grant provided by the Chancellor for Research of Mashhad University of Medical Sciences, Mashhad, Iran; Also the Organizational Ethics Committee of the Mashhad University of Medical Sciences approved the research project, under code IR.MUMS.REC.1400.181

Consent of publication: Informed consent was taken from the patient.

Availability of data: All data of this case was available.

Competing interest: None.

Funding: The Chancellor for Research of Mashhad University of Medical Sciences, Mashhad, Iran, supported this report.

Author’s contribution: Dr EVM an MHK collect patient’s data; all authors have prepared this manuscript.

References

1. Natarajan M. 14 Drug Trafficking. International crime and justice. 2010: 109.
2. Mehrpour O, Sezavar SV. Diagnostic imaging in body packers. InMayo Clinic Proceedings. 2012; 87: e53-e54. Elsevier.
3. Evans DC, Wojda TR, Jones CD, Otey AJ, Stawicki SP, et al. Intentional ingestions of foreign objects among prisoners: A review. World journal of gastrointestinal endoscopy. 2015; 7: 162.
4. Traub SJ, Hoffman RS, Nelson LS. Body packing—the internal concealment of illicit drugs. New England Journal of Medicine. 2003; 349: 2519-2526.
5. Flach PM, Ross SG, Ampanozi G, Ebert L, Germerott T, Hatch GM, et al. “Drug mules” as a radiological challenge: Sensitivity and specificity in identifying internal cocaine in body packers, body pushers, and body stuffers by computed tomography, plain radiography and Lodox. European journal of radiology. 2012; 81: 2518-2526.
6. Shadnia S, Faiaz-Noori MR, Pajoumand A, Talaie H, Khoshkar A, et al. A case report of opium body packer; review of the treatment protocols and mechanisms of poisoning. Toxicology mechanisms and methods. 2007; 17: 205-214.
7. Forouzesh M, Fallah F. Case Report: Sudden Death of a Healthy Body Packer: A Case Study. International Journal of Medical Toxicology and Forensic Medicine. 2017; 7: 227-230.
8. Abouzahir H, Nya S, Belhouss A, Benyaich H. Death following cocaine poisoning in body packer: Two cases report and review of the literature. Int. J. Forensic Med. 2020; 2: 14-16.
9. Hantson P, Capron A, Maillart JF. Oesophageal and gastric obstruction in a cocaine body packer. Journal of forensic and legal medicine. 2014; 27: 62-64.
10. Gill JR, Graham SM. Ten years of “body packers” in New York City: 50 deaths. Journal of Forensic Science. 2002; 47: 1-4.
11. Bulakci M, Kalelioglu T, Bulakci BB, Kiris A. Comparison of diagnostic value of multidetector computed tomography and X-ray in the detection of body packing. European journal of radiology. 2013; 82: 1248-1254.
12. Taheri MS, Moharamzad Y, Nahvi V. Abdominal CT findings of ruptured opium packets in a body packer. European Journal of Radiology Extra. 2009; 70: e21-e23.
13. HASANIAN MH, ABOU ALMASOUMI Z. Consequence of body packing of illicit drugs. Arch Iranian Med. 2007; 10: 20–23.
14. Olmedo R, Nelson L, Chu J, Hoffman RS. Is surgical decontamination definitive treatment of “body-packers”? The American journal of emergency medicine. 2001; 19: 593-596.
15. Vahabzadeh M, Mohammadi AB. Heroin body-packing and naloxone. The Lancet. 2019; 393: e35.